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IV.

NURSING PROCESS
Assessment Nursing Diagnosis neffecti!e airway clearance r"t accumulation of tracheobronchial secretions Plan/ Goal Outcome Criteria
General! #fter $%& days of nursing inter!ention patient will be able to establish and maintain airway patency'

Nursing Interventions
In$e"en$ent! $' ,onitor and record !ital signs &' #ssess patient-s condition' (' .le!ate head of bed and encourage fre/uent position changes' 4'0eep back dry and loosen clothing 1'#uscultate breath sounds and assess air mo!ement 2',onitor child for feeding intolerance and abdominal distention 3' nstruct the folks to pro!ide an increased fluid intake for the child 4' nstruct the folks to pro!ide ade/uate rest periods for the child

Rationale
In$e"en$ent! $'5o obtain baseline data &'5o know the patient-s general condition ('5o promote ma6imal inspiration, enhance e6pectoration of secretions in order to impro!e !entilation 4' 5o promote comfort and ade/uate !entilation 1'5o ascertain status and to note progress 2'5o a!oid compromising the airway 3'5o help li/uefy the secretions

Evaluation
#fter $%& days of )ursing nter!ention patient ha!e established and maintained airway patency'

Sub ective!

Ob ective!

Restlessness with nasal flaring With rales on both lung fields warm, flushed skin minimal colorless nasal secretions tachypnea RR=40bpm DOB tachycardia irritability chest indrawing cough

S"eci#ic! #fter (%4 hours of )ursing nter!ention, patient will be able to demonstrate* % impro!e airway %clearance reduction of congestion with breath sounds clear +RR impro!e

4'Rest will pre!ent fatigue and decrease o6ygen demands for metabolic demands

De"en$ent! %. administer due medications as ordered by the physician, bronchodilator s, anti pyretics and anti biotics' &. #dminister o6ygen therapy and other medications as ordered' Collaborative! $' #ssist respiratory therapist in performing nebuli7ation of the patient'

De"en$ent! $'bronchodilators decrease airway resistance, secondary to bronchoconstriction, anti pyretics alle!iate fe!er, antibiotics fight infection' &'indicated to increase o6ygen saturation'

Collaborative! %. )ebuli7ation is a fa!orable route of administering bronchodilator s and aid in e6pectorating secretions, hence patient-s breathing'

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